Efficacy of erenumab and factors predicting response after 3 months in treatment resistant chronic migraine: a clinical service evaluation

BackgroundCalcitonin gene-related peptide (CGRP) inhibitors have been developed as options for treatment of chronic and episodic migraine. We present our experience of the use of erenumab in a tertiary headache centre.MethodsThis was a prospective clinical audit of all patients commenced on erenumab following a locally agreed pathway and criteria over a consecutive period. Patients received monthly erenumab 140 mg for 3 months. Data were collected prospectively at baseline and 3 months follow up.ResultsOne hundred three patients were commenced on erenumab during the study period. Patients had tried a median of 7 previous prophylactics, including onabotulinum toxin A in 94%. At 3 months there was a reduction in median total (28 to 20, 29% reduction, p < 0.0001) and severe (15 to 5, 67% reduction, p < 0.0001) headache days. 39.8% of patients achieved at least a 30% reduction in total headache days; 61.8% of patients achieved at least a 50% reduction in severe headache days. Meeting either of these thresholds was considered a positive response, 68% of patients achieved this. Presence of daily headache pattern was negatively associated with response, (56% response vs. 90% without daily headache, p = 0.0003). There was no association between age, gender, presence of medication overuse or number of previously tried prophylactic treatments and response to erenumab. 43% of patients reported at least one adverse effect, most commonly constipation (26%); treatment was discontinued in 3 patients due to adverse effects.ConclusionsErenumab was an effective treatment for chronic migraine in this treatment resistant population over 3 months of follow up. Presence of daily headache predicted poorer response but there was still a significant positive response rate in this group.     

Cluster headache in childhood and adolescence: one-year prevalence in an out-patient population

Abstract A multicenter one-year study was carried out on 6629 headache patients under 18 years of age, attending 27 centers and clinics devoted to headache in Italy to identify the prevalence of cluster headache (CH) in childhood and adolescence. Two male CH patients aged 9 and 17 years were identified. Their attacks fulfilled the IHS criteria for CH, and they were classified as having cluster headache with undetermined periodicity and episodic cluster headache, respectively. The one-year prevalence in this headache out-patient population under 18 years of age was calculated to be 0.03%. This value is smaller than that derived in the general population. This finding further confirms the rarity of early diagnosis of this primary disorder in childhood and adolescence, as demonstrated in other studies.     

Almotriptan and its combination with aceclofenac for migraine attacks: a study of efficacy and the influence of auto-evaluated brush allodynia

Early treatment and combining a triptan with a non-steroidal anti-inflammatory drug (NSAID) are thought to improve outcome during migraine attacks, possibly by counteracting the negative influence of cutaneous allodynia. The aim of this multicentre, double-blind pilot study was to evaluate the prevalence of brush allodynia and its relative influence on the efficacy of a triptan-NSAID combination compared with headache intensity at the time of treatment. In a randomized, cross-over design, 112 migraineurs treated two moderate or severe attacks with almotriptan 12.5 mg combined with either aceclofenac 100 mg or placebo. Patients used a 2-cm brush to assess cutaneous allodynia. Allodynia was reported in 34.4% of attacks. The almotriptan-aceclofenac combination was numerically superior to triptan-placebo on 2-24-h sustained pain-free (P = 0.07), 2-h pain-free (P = 0.07) and headache recurrence (P = 0.05) rates, but not on 1-h headache relief. Allodynia numerically reduced treatment success overall, but this effect was not significant for the primary outcome measures. Headache intensity had a significant negative influence on 1-h relief in both attacks (P = 0.0001 and 0.0008, chi(2)) and on 2-24-h sustained pain-free rates in triptan-placebo-treated attacks (P = 0.013). Multivariate logistic regression analysis confirmed that headache intensity at treatment intake, rather than allodynia, significantly influenced most outcome measures, predominantly so in attacks treated with almotriptan and aceclofenac. In the latter, severe compared with moderate headache intensity reduced the likelihood of achieving the primary efficacy end-points [odds ratios (OR) 0.12 and 0.33], whereas allodynia was not a significant explanatory variable (OR 0.76 and 0.65). The results apply to the protocol used here and need to be confirmed in larger studies using quantitative sensory testing.     

Migraine,inflammatory bowel disease and celiac disease: A Mendelian randomization study

Objective

To assess whether migraine may be genetically and/or causally associated with inflammatory bowel disease (IBD) or celiac disease.

Background

Migraine has been linked to IBD and celiac disease in observational studies, but whether this link may be explained by a shared genetic basis or could be causal has not been established. The presence of a causal association could be clinically relevant, as treating one of these medical conditions might mitigate the symptoms of a causally linked condition.

Methods

Linkage disequilibrium score regression and two-sample bidirectional Mendelian randomization analyses were performed using summary statistics from cohort-based genome-wide association studies of migraine (59,674 cases; 316,078 controls), IBD (25,042 cases; 34,915 controls) and celiac disease (11,812 or 4533 cases; 11,837 or 10,750 controls). Migraine with and without aura were analyzed separately, as were the two IBD subtypes Crohn's disease and ulcerative colitis. Positive control analyses and conventional Mendelian randomization sensitivity analyses were performed.

Results

Migraine was not genetically correlated with IBD or celiac disease. No evidence was observed for IBD (odds ratio [OR] 1.00, 95% confidence interval [CI] 0.99–1.02, p = 0.703) or celiac disease (OR 1.00, 95% CI 0.99–1.02, p = 0.912) causing migraine or migraine causing either IBD (OR 1.08, 95% CI 0.96–1.22, p = 0.181) or celiac disease (OR 1.08, 95% CI 0.79–1.48, p = 0.614) when all participants with migraine were analyzed jointly. There was some indication of a causal association between celiac disease and migraine with aura (OR 1.04, 95% CI 1.00–1.08, p = 0.045), between celiac disease and migraine without aura (OR 0.95, 95% CI 0.92–0.99, p = 0.006), as well as between migraine without aura and ulcerative colitis (OR 1.15, 95% CI 1.02–1.29, p = 0.025). However, the results were not significant after multiple testing correction.

Conclusions

We found no evidence of a shared genetic basis or of a causal association between migraine and either IBD or celiac disease, although we obtained some indications of causal associations with migraine subtypes.     

Primary headache care delivery by nonspecialists in Brazil

Headaches are common disorders usually examined by nonneurologists. In order to assess how primary headache patients (IHS groups 1, 2, and 3) are generally managed by nonspecialists, 414 patients were asked about their previous headache care. Correct diagnosis had previously been made in only 44.9%, 6.7%, and 26.7% of the migraine, tension-type headache, and cluster headache patients, respectively. The patients underwent 501 investigative procedures motivated by the headache, averaging 1.21 examinations per patient, mostly EEGs. Preventive treatment was largely overlooked irrespective of the headache type. It is concluded that scientific improvements in headache care may be ineffective unless educational programs improve headache knowledge in general.